Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
Maternal blood pressure.
Level of pain sensation.
Station of presenting part.
Variability of fetal heart rate.
The Correct Answer is A
Choice A rationale
Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.
Choice B rationale
Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.
Choice C rationale
The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.
Choice D rationale
Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The ointment used in newborns does not dilate the pupil. It is not intended to aid in the visualization of the red reflex. The red reflex can be observed without the need for any ointment.
Choice B rationale
The ointment does not prevent herpes infections. It is specifically used to prevent bacterial eye infections caused by organisms such as Neisseria gonorrhoeae and Chlamydia trachomatis, which can be present in the birth canal.
Choice C rationale
The ointment will prevent eye infections. This is the correct explanation. The eye ointment, typically erythromycin or tetracycline, is applied to prevent ophthalmia neonatorum, a type of conjunctivitis caused by bacteria that the newborn might be exposed to during delivery.
Choice D rationale
The ointment will not clear the infant's vision. Newborns naturally have somewhat blurry vision at birth, and the ointment does not enhance or clear their vision. Its primary purpose is to prevent bacterial infections.
Correct Answer is B
Explanation
Choice A rationale
While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.
Choice B rationale
Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.
Choice C rationale
Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.
Choice D rationale
The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.
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